Time
in min
8
Acceptance-based techniques (defusion + acceptance)
[adapted from Hayes, Strosahl, & Wilson, 1999; Hayes et al., 1999; Gutierrez, Luciano,
Rodriguez, & Fink, 2004]
1. Provide a quick introduction of the program and why exercising is important (8
minutes)
2. Ice Cube exercise: Obtain baseline and solicit feedback (5 minutes)
3. Teach acceptance: (11 minutes)
 The unwelcome party guest (acceptance)
 If-then statements for acceptance applied to the experiential exercise (i.e., holding an
ice cube). If-then plans will be used to aid in the application of the acceptance-based
techniques during the ice cube test and the exercise session.
4. Teach defusion: (6 minutes)
 "I am having the thought/feeling that …" (defusion)
 If-then statements for defusion applied to the experiential exercise (i.e., holding an ice
cube).
5. Practice the acceptance-based techniques with an ice cube: Participants will have the
opportunity to practice acceptance and defusion while holding an ice cube. (5 minutes)
6. Make if-then plans for acceptance and defusion applied to the cycle ergometer
exercise test. (5 minutes)
 The acceptance-based training will take 40 minutes to complete
1.0 Provide a quick introduction of the program
It is important to discuss and remind the participant throughout of how important they find to engage in more
exercise behavior. The specific goal for you, as a therapist, in this intervention is to get the participants to be able to
move forward (continue to exercise) with what is important for them (exercising), even in the presence of
uncomfortable thoughts, emotions, feelings, or bodily sensations. In other words not to change the content of their
thoughts and emotions but rather to show them how they can relate to them in a different way, by not attempting to
suppress them nor control them.

This psychological intervention has the ultimate goal of helping you to exercise for
longer. I will teach you two cognitive strategies aimed at your thoughts, feelings, and
physical pain that you might have felt while exercising, and to help you to view them in a
different way - so that they are less disruptive - and that way you can continue exercising
for longer. Any questions at this point? Ok, let's begin.

We understand that increasing your physical activity is important for you. Let’s explore a
little why it is important for you. I want you to sit back comfortably and think for a minute
about 2 things: 1) why is exercising important for you to exercise; and 2) what concrete
goals do you want to achieve. For instance, my goal is to lose weight by the beginning of
the summer. But it is important for me to lose weight because that would give me
confidence, and confidence is something that is important to me and I value that.
Now close your eyes and to take a moment to imagine what makes it important for you to
increase your exercising.


Great, thank you – I hope that was relaxing and pleasant for you. Were you able to
imagine what is important to you about increasing your exercise behavior?

Now, some people find that while exercising that they feel pain, or shortness of breath,
they find it boring. Basically, your mind can come up with very clever and creative ways
to make you stop working. What thoughts and feelings show up for you while exercising?
1
[You can record the responses and use them as examples later in the discussion]
5

So, what do you do when these thoughts and sensations show up? [They may say Distract by listening to music]  whatever cognitive barrier they mentioned, say: Do
these strategies work in the long term? [If they say, I stop exercising … ask them: Does
that get you closer or further from what is important for you?]

So one hand you have this thing that is important for you – increasing your exercising and
on the other you have these thoughts and feelings that are obstacles and don’t go away –
at least based on what you have tried, nothing has helped you to deal with them. In the
service of pushing your limits of exercising would you try something different today?

The way that we will spend the next 30 minutes will be for you to learn how you can
relate in a different to these thoughts and feelings that can make exercising difficult and
unpleasant. Do you have any questions so far?
2.0 Ice cube exercise
Purpose: 1. Experiential exercise for the purpose of teaching acceptance-based techniques
2. As the experimenter explains the acceptance-based techniques, the participant can relate to their experience of
holding the ice cube (e.g., "I can't stand this pain"; "It's too cold"; "My hand is numb and I want to let go"). These
examples, and others that the participant generates, can be used to illustrate and practice the acceptance-based
techniques.
3. The ice-cube exercise will also be an opportunity to teach participants how to identify their feelings towards the
task (pleasant/unpleasant) and the perceived intensity of the pain.

Ok before we start the actual training, I will ask you to do a silly little exercise with me. I
want you to hold this ice cube for as long as you can [don’t tell the participants that you will stop
the exercise after 120 sec].

Your task is to become aware of what thoughts and feeling show up as you hold the ice
cube.
Procedures:
Step 1: Place an ice cube in the participant’s hand (alternate the hands between baseline and the second trial of
holding the ice cube) [record the amount of time (in seconds) that the participant held the ice cube]. Participants
will be asked to simply let go off the ice cube in the tissue provided when they can no longer tolerate the pain.
For safety purposes the task will be terminated after 120 seconds.
Step 2: Ask the following questions when the participant is no longer holding the ice cube:


What thoughts did you have while holding the ice cube? The participant may list, for example
"my hand was numb"; “it was painful” [record participant’s responses]. What else showed up?
What did you do when these thoughts came up? [They may say things like – distract/drop] … In
this case this is not an important – but if holding ice cubes for a long time was important for you then these
thoughts and feelings that show up would be problem].



It is also common to have pleasant or unpleasant reactions to holding the ice cube. With 1
representing very bad feeling and 5 very good feeling - How good or bad did you feel
during the time that you were holding the ice cube?
On a scale from 1 to 10, with 1 representing no pain and 10 representing extreme pain.
How intense did you find that the pain? [record participant’s responses].
How well are you able to differentiate the two constructs - affect and pain intensity? [If
they don’t understand the difference explain that: Your pain perception depends on your physiological
sensations. That is, the extent to which for example you felt burning in your hand or numbness in your
fingers. Whereas affect is less related to one's physiological sensations, the burning pain.]
2

11
In the next part I am going to teach the cognitive strategies that I mentioned earlier that
can help you to relate to such physical sensations, thoughts, and feelings in a different
way.
3.0 Teach acceptance-based techniques: Acceptance

So, the first psychological strategy is called cognitive-acceptance, or your willingness to
behave in a desired way, in this case to exercise as long as you can, regardless of what
you are thinking, feeling, or experiencing - such as painful physical sensations. This
technique is not about struggling to suppress, changing or manipulate your thoughts - but
simply to notice what you are thinking, feeling, and experiencing (e.g., pain) AND to
continue to exercise.

Willingness to experience, your bodily sensations, thoughts, and feelings is optimal
because it is often impossible to get rid of things that are in your mind, such as unpleasant
feelings and thoughts (e.g., 'don’t think of the pain' - may actually cause thoughts of pain
and increase such sensations).

Let me give you an example, I'll ask you to close your eyes and imagine that I’m going to
give you a million dollars but whatever you do, do not think about a pink elephant. Don’t
think about the pink elephant! Go! Now what showed up in your mind? [They’ll likely say
pink elephant]

BUT when you are not concerned about suppressing or distracting from thoughts and
feelings - it can actually start to feel liberating, and you can re-direct all your energy and
attention that you would otherwise spent in controlling your thoughts - you can use it to
continue to push yourself and exercise for longer, and thereby reap more benefits from the
activity.

Ok so let's learn more about this technique using an easy to understand metaphor,
with a short 4-minute video clip.

While you are watching this video see how you can relate the metaphor that you are about
to see with your exercising experience. We’ll have a chance to discuss it after.
http://www.youtube.com/watch?v=VYht-guymF4
 So, how could this be a metaphor for accepting feelings, thoughts and physical pain while
exercising? [Let the participant make the connection between Brian and the pain and negative feelings
during exercise]
 Right, the 3 take away messages from the metaphor are:
1. It's hard to control our thoughts and feelings, they always come back. - We saw this with
the pink elephant; and when Brian kept coming back to the party.
2. Not struggling with your negative thoughts and feelings, allows you to continue with
your goals, and accomplish them. - in the metaphor, the host was finally able to
accomplish his goal of being with his friends only after he stopped kicking Brian out and
willingly allowed him to be part of the party.
3. Willingly making room for the unhelpful thoughts and feelings, accepting them as part
of your experience, changes your relationship with them, and they might no longer
seem so important and in need for action. The host still found Brian to be a pain and to
3
smell, but he saw him as less rowdy, and even found him to have a quirky sense of humor.
 So, during the exercise session when you have unhelpful thoughts and you are in physical
discomfort, you may find them distressing, just like Brian was to his neighbours. But if
you are not struggling to control, suppress, or eliminate them, you can actually make
room for them, and then you can direct your energy and attention and efforts to other
areas, such as listening to your music, reminding yourself why exercising is important for
you, and to continue with your goal today - which is to exercise as long as you can.
 While you are exercising you can tell yourself: "I don’t need to make it go away, I'll let
them be in my head".
 This way you can develop the ability to feel or think badly AND to continue to exercise.
Does it make sense so far? What questions do you have?
 I know that I have said a lot, but in a short little while you will have the opportunity to
practice the metaphor, by holding an ice cube.
3.2 if-then statements for acceptance
 Ok, so let's talk about how you can apply this technique in the midst of you cycling.
Research shows that using if-then plans if-then plans- helps one to accomplish their goals.
For instance, “If thoughts of pain show up, then I will make room for them and continue
to exercise.”
 So, this second time around, whenever an unhelpful thought or feeling comes to mind, tell
yourself "if I am bored, for example, then I will make room for this feeling and continue to
exercise.” Does that make sense?
 Now you come up with two if-then statements where you can use acceptance to while
holding an ice cube again, and later you'll make some specific for exercising [depending on
how much time you have, you may ask the participant to make only 1]
 Very well, you got it!
4.0 Teach acceptance-based techniques: Defusion (6 min)
Thoughts and feelings do not lead to behaviour
Purpose: Aim of this section is to teach you the limits of language, showing you that language (choice of words
and/or feelings) can be distinguished from what we actually do (i.e., our behavior and experiences).
 The second technique that I want to teach you is called cognitive defusion. Before I go
further, I want you to give me an example when you had strong intense thoughts that you
wanted to do something, but you ended up doing something else instead? [Give participant a
minute to come up with an example].
 This was a great example because traditionally we tend to think that our thoughts have a
great influence on how we feel and what we do… But from the example that you just
gave me, it seems that at times you can act in ways that are opposite from what you are
thinking and feeling, despite how strong and intense those thoughts are.
 So, cognitive defusion is when you take your thoughts to be literal or absolute truths. This
technique will help you to disentangle your thoughts from influencing your feelings and
your behaviour. In other words you can learn to not act on your thoughts.
4
Step 2: Teach the phrase associated with defusion:
 So to help you disconnect from your unhelpful thoughts or feelings, I want you to learn a
phrase, and the phrase, is "I am having the thought that…”
 Adding this phrase BEFORE your sensation will create the space, or distance, between
your thoughts and feelings from your behaviour:
 "I'm having the feeling that my hand is numb" as opposed to "my hand is numb" do you
see how this is different from saying "my hand is numb"
 The idea here is that your behavior can be directed not by your internal experiences and
emotions but rather by your goals and valued directions. In other words, you can have
muscle pain, feel fatigued, and sweat, but can continue to exercise, and using this phrase
will allow you to distance yourself from them in an easy way. Do you have any questions
so far?
4.1 Summary of defusion and if-then statements
 Using this language, "I’m having the thought/feeling that …" will reduce the grip that
those thoughts and emotions have on behavior- it will create some distance: “If I have the
thought that I want to let go of the ice cube, then I will tell myself that it is only a thought
and that I can continue to hold the ice cube.”
 Now you come up with some if-then statements where you can use defusion to help you
accept a thought or a feeling for holding the ice cube, and later we'll make some
specifically for exercising [If you are running out of time, create only one if-then plan for
the ice cube exercise.].
Very well, you got it!
 Do you have any questions before we go ahead with the next part?
5
5.0 Practice the acceptance and defusion with an ice cube
Purpose: Aim of this session is for the participant to hold an ice cube as long as they can and to apply the
acceptance-based techniques. (Unknown to the participants, for safety purposes the task will be discontinued after
120 seconds.)
Now, I am going to ask you again to hold the ice-cube and to apply the strategies that you
learned. Do a very quick recap:
 To recap, you saw the Unwelcome Party Guest metaphor, and that helped you to
understand how to accept unhelpful feelings and thoughts; and you came up with if-then
statements: e.g., “If thoughts of pain show up, then I will make room for them and
continue to hold the ice cube”
 Secondly you learned that when the negative thoughts and feelings become very intense
you can defuse from them by saying, what phrase?: "I am having the thought that…" or "I
am having the feeling that …" The if-then statements for defusion that you came up are:
e.g., “If I have the thought that I want to let go of the ice cube, then I will tell myself that
it is only a thought and that I can continue to hold the ice cube.”
 Ok so let's try the techniques using the ice cube.
[The experimenter will place the ice cube in the participant’s hand].
5

Remember to use the techniques and to hold the ice cube as long as you can. Go ahead.
[record the amount of time and show the participant how they did compared to the first time they held the
ice cube]
6.1 Solicit participants’ experiences (go over as many questions as time permitting, ensuring that the
participant will have enough time for section 6.0)
Ask the following questions when the participant is no longer holding the ice cube:
 What thoughts did you have while holding the ice cube? The participant may list, for example
"my hand was numb"; “it was painful”.

5
1 representing very bad and 5 very good - How good or bad did you feel during the time
that you were holding the ice cube?
 With 1 representing no pain and 10 representing extreme pain to describe how intense you
found the pain?
 How well were you able to not struggle, or suppress, but to make room for whatever
thoughts and feelings you had?
 How well were you able to achieve distance, that is defuse your thoughts from your
feelings and behaviour?
 How challenging was it? What made it challenging?
 How helpful did you find the if-then plans?
 If you found holding the ice cube difficult, do not give up yet! Acceptance and defusing is
a new way of responding to your internal experiences and so it takes practice.
6.0 Make if-then plans for acceptance and defusion applied to exercising
Purpose: The participant will generate if-then statements relevant to exercising.
 Now that you have learned and successfully applied both techniques: acceptance and
defusion using the ice cube, let's come up with if-then statements that you can apply
specifically to exercising.
 For example, if-then statements for acceptance applied to exercising are:“If feelings of
exhaustion show up, then I will make room for these feelings and continue to exercise”,
or “If I notice that I feel breathless, then I will make room for this feeling and continue to
exercise”
 If-then statements for defusion applied to exercising are: “If thoughts and feelings of
intense pain in my legs show up, then I will tell myself that it is only a feeling and that I
can keep going"; or "If thoughts that I want to stop exercising show up, then I will tell
myself that it is only a thought and that I can keep going"
 Now you come up with some if-then statements where you can use acceptance, rather then
struggle and suppression to help you make room for unhelpful thoughts or feelings while
you are exercising today. [record participant’s responses and review them]
 Now let's come up with some if-then statements where you can use defusion to help you
distance from your thoughts/feelings while you are exercising today. [record
participant’s responses and review them]
References:
Gutierrez O, Luciano C, Rodriguez M, Fink BC. Comparison between an acceptance –based and a cognitivecontrol based protocol for coping with pain. Behav Ther. 2004(4);35:767-783.
Hayes SC, Bissett RT, Korn Z, et al. The impact of acceptance versus control rationales on pain tolerance.
Psychol Rec. 1999;49:33-47.
Hayes SC, Strosahl KD, Wilson KG. Acceptance and commitment therapy: An experiential approach to
behavior change. New York (NY): Guilfod Press; 1999. p. 1-304.
6